Basic Information
| Provider Information | |||||||||
| NPI: | 1013176940 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CANCER CARE CENTERS OF BREVARD INC | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 534595 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303534595 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3219520898 | ||||||||
| FaxNumber: | 3219526296 | ||||||||
| Practice Location | |||||||||
| Address1: | 13050 US HIGHWAY 1 | ||||||||
| Address2: | |||||||||
| City: | SEBASTIAN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329583733 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3219520898 | ||||||||
| FaxNumber: | 3219526296 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2008 | ||||||||
| LastUpdateDate: | 11/24/2009 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CHARLES | ||||||||
| AuthorizedOfficialFirstName: | SILAS | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3219520898 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | CL7578 | 01 | FL | RR MEDICARE | OTHER | 372996605 | 05 | FL | MEDICAID |